Use of the omentum in the management of sternal wound infection after cardiac transplantation.

Seven patients with deep sternal wound infection after orthotopic cardiac transplantation were treated at the Medical College of Virginia-McGuire Veterans Administration Hospitals over a 3-year period. Six patients had mediastinitis with pericardial abscess, and one patient had only sternal osteomyelitis. All patients underwent prompt sternal debridement. In the six patients with mediastinitis, the transplanted heart was surrounded by a large dead space after debridement. This space appeared to result from a size mismatch between the remaining enlarged pericardial sac and the new normal-sized transplanted heart. Wound closure was done at the time of debridement in all patients except one who was closed 3 days later. A pedicled omental flap based on the right gastroepiploic artery was used in five of the six patients with mediastinitis, and these five patients healed their wounds and resolved their infection. Three of these patients are alive and well and two died of later complications other than sternal infection. The patient with only sternal osteomyelitis healed uneventfully. When mediastinitis and intrapericardial infection is present after cardiac transplantation, the omentum appears to provide adequate bulk for obliteration of the large dead space that remains after debridement. This surgery, combined with antibiotic therapy and temporary reduction of immunosuppression, can treat sternal wound infection successfully after cardiac transplantation. Mortality from other complications can occur, however, and not all patients survive.